S. 7882 2
S 2. Subsection (l) of section 3221 of the insurance law is amended by
adding a new paragraph 19 to read as follows:
(19) (A) EVERY GROUP OR BLANKET POLICY DELIVERED OR ISSUED FOR DELIV-
ERY IN THIS STATE WHICH PROVIDES MAJOR MEDICAL OR SIMILAR COMPREHEN-
SIVE-TYPE COVERAGE SHALL INCLUDE SPECIFIC COVERAGE FOR DIAGNOSIS AND
TREATMENT OF SUBSTANCE USE DISORDER BENEFITS PURSUANT TO THE FEDERAL
PAUL WELLSTONE AND PETE DOMENICI MENTAL HEALTH PARITY AND ADDICTION
EQUITY ACT OF 2008, AS AMENDED, OR OTHER APPLICABLE FEDERAL AND STATE
STATUTES AND RULES AND REGULATIONS PROMULGATED THERETO WHICH REQUIRE
PARITY BETWEEN MENTAL HEALTH OR SUBSTANCE USE DISORDER BENEFITS AND
MEDICAL/SURGICAL BENEFITS WITH RESPECT TO FINANCIAL REQUIREMENTS AND
TREATMENT OR WHICH REQUIRE COVERAGE OF SUCH TREATMENT, WHICHEVER
PROVIDES A BENEFIT THAT IS MORE ADVANTAGEOUS TO THE POLICYHOLDER AS
DETERMINED BY THE SUPERINTENDENT. SUCH COVERAGE SHALL INCLUDE BOTH INPA-
TIENT AND OUTPATIENT TREATMENT, INCLUDING DETOXIFICATION AND REHABILI-
TATION SERVICES.
(B) IN THE EVENT OF AN ADVERSE DETERMINATION FOR CHEMICAL DEPENDENCE
OR SUBSTANCE USE DISORDER TREATMENT SERVICES, THE HEALTH PLAN SHALL
CONTINUE TO PROVIDE COVERAGE AND REIMBURSE FOR ALL SUCH SERVICES UNTIL
THE INSURED HAS EXHAUSTED ALL APPEALS, BOTH INTERNAL AND EXTERNAL, OR
OTHERWISE NOTIFIES THE HEALTH PLAN IN WRITING THAT HE OR SHE HAS DECIDED
TO NOT MOVE FORWARD WITH THE APPEALS PROCESS. THE HEALTH PLAN SHALL
ENSURE THAT AN INSURED SHALL NOT INCUR ANY GREATER OUT-OF-POCKET COSTS
FOR SUBSTANCE USE DISORDER TREATMENT SERVICES RENDERED WHILE THE PROVID-
ER IS APPEALING AN ADVERSE DETERMINATION FOR SUCH SERVICES THAN THE
INSURED WOULD HAVE INCURRED IF SUCH SERVICES WERE APPROVED BY THE UTILI-
ZATION REVIEW AGENT.
S 3. Section 4303 of the insurance law is amended by adding a new
subsection (oo) to read as follows:
(OO) (1) A MEDICAL EXPENSE INDEMNITY CORPORATION, A HOSPITAL SERVICE
CORPORATION OR A HEALTH SERVICE CORPORATION WHICH PROVIDES MAJOR MEDICAL
OR SIMILAR COMPREHENSIVE-TYPE COVERAGE SHALL INCLUDE SPECIFIC COVERAGE
FOR DIAGNOSIS AND TREATMENT OF SUBSTANCE USE DISORDER BENEFITS PURSUANT
TO THE FEDERAL PAUL WELLSTONE AND PETE DOMENICI MENTAL HEALTH PARITY AND
ADDICTION EQUITY ACT OF 2008, AS AMENDED, OR OTHER APPLICABLE FEDERAL
AND STATE STATUTES AND RULES AND REGULATIONS PROMULGATED THERETO WHICH
REQUIRE PARITY BETWEEN MENTAL HEALTH OR SUBSTANCE USE DISORDER BENEFITS
AND MEDICAL/SURGICAL BENEFITS WITH RESPECT TO FINANCIAL REQUIREMENTS AND
TREATMENT OR WHICH REQUIRE COVERAGE OF SUCH TREATMENT, WHICHEVER
PROVIDES A BENEFIT THAT IS MORE ADVANTAGEOUS TO THE POLICYHOLDER AS
DETERMINED BY THE SUPERINTENDENT. SUCH COVERAGE SHALL INCLUDE BOTH INPA-
TIENT AND OUTPATIENT TREATMENT, INCLUDING DETOXIFICATION AND REHABILI-
TATION SERVICES.
(2) IN THE EVENT OF AN ADVERSE DETERMINATION FOR CHEMICAL DEPENDENCE
OR SUBSTANCE USE DISORDER TREATMENT SERVICES, THE HEALTH PLAN SHALL
CONTINUE TO PROVIDE COVERAGE AND REIMBURSE FOR ALL SUCH SERVICES UNTIL
THE INSURED HAS EXHAUSTED ALL APPEALS, BOTH INTERNAL AND EXTERNAL, OR
OTHERWISE NOTIFIES THE HEALTH PLAN IN WRITING THAT HE OR SHE HAS DECIDED
TO NOT MOVE FORWARD WITH THE APPEALS PROCESS. THE HEALTH PLAN SHALL
ENSURE THAT AN INSURED SHALL NOT INCUR ANY GREATER OUT-OF POCKET COSTS
FOR SUBSTANCE USE DISORDER TREATMENT SERVICES RENDERED WHILE THE PROVID-
ER IS APPEALING AN ADVERSE DETERMINATION FOR SUCH SERVICES THAN THE
INSURED WOULD HAVE INCURRED IF SUCH SERVICES WERE APPROVED BY THE UTILI-
ZATION REVIEW AGENT.
S 4. Section 4902 of the insurance law is amended by adding two new
subsections (c) and (d) to read as follows:
S. 7882 3
(C) I. WHEN CONDUCTING A UTILIZATION REVIEW FOR PURPOSES OF DETERMIN-
ING HEALTH CARE COVERAGE FOR CHEMICAL DEPENDENCE OR SUBSTANCE USE DISOR-
DERS, A UTILIZATION REVIEW AGENT SHALL BE A HEALTH CARE PROVIDER WHO
SPECIALIZES IN BEHAVIORAL HEALTH AND WHO HAS EXPERIENCE IN THE DELIVERY
OF CHEMICAL DEPENDENCE OR SUBSTANCE USE DISORDER COURSES OF TREATMENT TO
SUPERVISE AND OVERSEE THE MEDICAL MANAGEMENT DECISIONS RELATING TO SUCH
TREATMENT.
II. A UTILIZATION REVIEW AGENT SHALL UTILIZE RECOGNIZED EVIDENCE-BASED
AND PEER REVIEWED CLINICAL REVIEW CRITERIA THAT IS APPROPRIATE TO THE
AGE OF THE PATIENT AND IS DEEMED APPROPRIATE AND APPROVED FOR SUCH USE
BY THE COMMISSIONER OF THE OFFICE OF ALCOHOLISM AND SUBSTANCE ABUSE
SERVICES IN CONSULTATION WITH THE COMMISSIONER OF HEALTH AND THE SUPER-
INTENDENT.
III. THE OFFICE OF ALCOHOLISM AND SUBSTANCE ABUSE SERVICES IN CONSUL-
TATION WITH THE COMMISSIONER OF HEALTH AND THE SUPERINTENDENT SHALL
APPROVE A RECOGNIZED EVIDENCE-BASED AND PEER REVIEWED CLINICAL REVIEW
CRITERIA, IN ADDITION TO ANY OTHER APPROVED EVIDENCE-BASED AND PEER
REVIEWED CLINICAL REVIEW CRITERIA.
(D) WHERE AN INSURED'S HEALTHCARE PROVIDER BELIEVES AN IMMEDIATE
APPEAL OF AN ADVERSE DETERMINATION FOR TREATMENT RELATING TO CHEMICAL
DEPENDENCE OR SUBSTANCE USE DISORDER IS WARRANTED, ALL INTERNAL APPEALS
SHALL BE CONDUCTED ON AN EXPEDITED BASIS AS SET FORTH IN SUBSECTION (B)
OF SECTION FOUR THOUSAND NINE HUNDRED FOUR OF THIS ARTICLE. WHERE AN
INSURED'S HEALTH CARE PROVIDER DETERMINES THAT A DELAY IN PROVIDING
CHEMICAL DEPENDENCE OR SUBSTANCE USE DISORDER TREATMENT WOULD POSE A
SERIOUS THREAT TO THE HEALTH OR SAFETY OF THE INSURED, EXTERNAL APPEALS
OF UTILIZATION REVIEW DETERMINATION WILL BE CONDUCTED ON AN EXPEDITED
BASIS AS SET FORTH IN PARAGRAPH THREE OF SUBSECTION (B) OF SECTION FOUR
THOUSAND NINE HUNDRED FOURTEEN OF THIS ARTICLE.
S 5. Subsection (c) of section 4903 of the insurance law, as amended
by chapter 237 of the laws of 2009, is amended to read as follows:
(c) A utilization review agent shall make a determination involving
continued or extended health care services, additional services for an
insured undergoing a course of continued treatment prescribed by a
health care provider, REQUESTS FOR TREATMENT FOR CHEMICAL DEPENDENCE OR
SUBSTANCE USE DISORDER, or home health care services following an inpa-
tient hospital admission, and shall provide notice of such determination
to the insured or the insured's designee, which may be satisfied by
notice to the insured's health care provider, by telephone and in writ-
ing within one business day of receipt of the necessary information
except, with respect to home health care services following an inpatient
hospital admission OR REQUESTS FOR TREATMENT FOR CHEMICAL DEPENDENCE OR
SUBSTANCE USE DISORDER, within seventy-two hours of receipt of the
necessary information when the day subsequent to the request falls on a
weekend or holiday. Notification of continued or extended services shall
include the number of extended services approved, the new total of
approved services, the date of onset of services and the next review
date. Provided that a request for home health care services and all
necessary information is submitted to the utilization review agent prior
to discharge from an inpatient hospital admission pursuant to this
subsection, a utilization review agent shall not deny, on the basis of
medical necessity or lack of prior authorization, coverage for home
health care services while a determination by the utilization review
agent is pending. PROVIDED THAT A REQUEST FOR TREATMENT FOR CHEMICAL
DEPENDENCE OR SUBSTANCE USE DISORDER AND ALL NECESSARY INFORMATION IS
SUBMITTED TO THE UTILIZATION REVIEW AGENT PURSUANT TO THIS SUBSECTION, A
S. 7882 4
UTILIZATION REVIEW AGENT SHALL NOT DENY, ON THE BASIS OF MEDICAL NECES-
SITY OR LACK OF PRIOR AUTHORIZATION, COVERAGE FOR CHEMICAL DEPENDENCE OR
SUBSTANCE USE DISORDER TREATMENT WHILE A DETERMINATION BY THE UTILIZA-
TION REVIEW AGENT IS PENDING. PROVIDED THAT UPON ADMISSION TO INPATIENT
AND RESIDENTIAL TREATMENT FOR CHEMICAL DEPENDENCY OR SUBSTANCE USE
DISORDER, THE UTILIZATION REVIEW AGENT SHALL NOT DENY, ON THE BASIS OF
MEDICAL NECESSITY OR LACK OF PRIOR AUTHORIZATION, WHEN NOTICE OF ADMIS-
SION FOR PURPOSES OF CARE COORDINATION WAS PROVIDED TO THE UTILIZATION
REVIEW AGENT WITHIN TWENTY-FOUR HOURS OF AN ADMISSION; AND A REQUEST FOR
TREATMENT FOR CHEMICAL DEPENDENCE OR SUBSTANCE USE DISORDER AND ALL
NECESSARY INFORMATION IS SUBMITTED TO THE UTILIZATION REVIEW AGENT
PURSUANT TO THIS SUBSECTION.
S 6. Subsection (b) of section 4904 of the insurance law, as amended
by chapter 237 of the laws of 2009, is amended to read as follows:
(b) A utilization review agent shall establish an expedited appeal
process for appeal of an adverse determination involving (1) continued
or extended health care services, procedures or treatments or additional
services for an insured undergoing a course of continued treatment
prescribed by a health care provider or home health care services
following discharge from an inpatient hospital admission pursuant to
subsection (c) of section four thousand nine hundred three of this arti-
cle or (2) an adverse determination in which the health care provider
believes an immediate appeal is warranted except any retrospective
determination. Such process shall include mechanisms which facilitate
resolution of the appeal including but not limited to the sharing of
information from the insured's health care provider and the utilization
review agent by telephonic means or by facsimile. The utilization review
agent shall provide reasonable access to its clinical peer reviewer
within one business day of receiving notice of the taking of an expe-
dited appeal. Expedited appeals shall be determined within two business
days of receipt of necessary information to conduct such appeal. Expe-
dited appeals which do not result in a resolution satisfactory to the
appealing party may be further appealed through the standard appeal
process, or through the external appeal process pursuant to section four
thousand nine hundred fourteen of this article as applicable. PROVIDED
THAT THE INSURED OR THE INSURED'S HEALTH CARE PROVIDER NOTIFIES THE
UTILIZATION REVIEW AGENT OF ITS INTENT TO FILE AN EXTERNAL APPEAL IMME-
DIATELY UPON RECEIPT OF AN APPEAL DETERMINATION AND A REQUEST FOR AN
EXPEDITED EXTERNAL APPEAL FOR TREATMENT OF CHEMICAL DEPENDENCE OR
SUBSTANCE USE DISORDER AND ALL NECESSARY INFORMATION IS SUBMITTED WITHIN
TWENTY-FOUR HOURS OF RECEIPT OF AN APPEAL DETERMINATION, A UTILIZATION
REVIEW AGENT SHALL NOT DENY, ON THE BASIS OF MEDICAL NECESSITY OR LACK
OF PRIOR AUTHORIZATION, COVERAGE FOR SUCH TREATMENT WHILE A DETERMI-
NATION BY THE EXTERNAL REVIEW AGENT IS PENDING.
S 7. Section 4902 of the public health law is amended by adding two
new subdivisions 3 and 4 to read as follows:
3. I. WHEN CONDUCTING A UTILIZATION REVIEW FOR PURPOSES OF DETERMINING
HEALTH CARE COVERAGE FOR CHEMICAL DEPENDENCE OR SUBSTANCE USE DISORDERS,
A UTILIZATION REVIEW AGENT SHALL BE A HEALTH CARE PROVIDER WHO SPECIAL-
IZES IN BEHAVIORAL HEALTH AND WHO HAS EXPERIENCE IN THE DELIVERY OF
CHEMICAL DEPENDENCE OR SUBSTANCE USE DISORDER COURSES OF TREATMENT TO
SUPERVISE AND OVERSEE THE MEDICAL MANAGEMENT DECISIONS RELATING TO SUCH
TREATMENT.
II. A UTILIZATION REVIEW AGENT SHALL UTILIZE RECOGNIZED EVIDENCE-BASED
AND PEER REVIEWED CLINICAL REVIEW CRITERIA THAT IS APPROPRIATE TO THE
AGE OF THE PATIENT AND IS DEEMED APPROPRIATE AND APPROVED FOR SUCH USE
S. 7882 5
BY THE COMMISSIONER OF THE OFFICE OF ALCOHOLISM AND SUBSTANCE ABUSE
SERVICES IN CONSULTATION WITH THE COMMISSIONER AND THE SUPERINTENDENT OF
FINANCIAL SERVICES.
III. THE OFFICE OF ALCOHOLISM AND SUBSTANCE ABUSE SERVICES IN CONSUL-
TATION WITH THE COMMISSIONER AND THE SUPERINTENDENT OF FINANCIAL
SERVICES SHALL APPROVE A RECOGNIZED EVIDENCE-BASED AND PEER REVIEWED
CLINICAL REVIEW CRITERIA, IN ADDITION TO ANY OTHER APPROVED
EVIDENCE-BASED AND PEER REVIEWED CLINICAL REVIEW CRITERIA.
4. WHERE AN INSURED'S HEALTHCARE PROVIDER BELIEVES AN IMMEDIATE APPEAL
OF AN ADVERSE DETERMINATION FOR TREATMENT RELATING TO CHEMICAL DEPEND-
ENCE OR SUBSTANCE USE DISORDER IS WARRANTED, ALL INTERNAL APPEALS SHALL
BE CONDUCTED ON AN EXPEDITED BASIS AS SET FORTH IN SUBSECTION (B) OF
SECTION FOUR THOUSAND NINE HUNDRED FOUR OF THIS TITLE. WHERE AN
ENROLLEE'S HEALTH CARE PROVIDER DETERMINES THAT A DELAY IN PROVIDING
CHEMICAL DEPENDENCE OR SUBSTANCE USE DISORDER TREATMENT WOULD POSE A
SERIOUS THREAT TO THE HEALTH OR SAFETY OF THE ENROLLEE, EXTERNAL APPEALS
OF UTILIZATION REVIEW DETERMINATIONS WILL BE CONDUCTED ON AN EXPEDITED
BASIS AS SET FORTH IN PARAGRAPH (C) OF SUBDIVISION TWO OF SECTION FOUR
THOUSAND NINE HUNDRED FOURTEEN OF THIS ARTICLE.
S 8. Subdivision 3 of section 4903 of the public health law, as
amended by chapter 237 of the laws of 2009, is amended to read as
follows:
3. A utilization review agent shall make a determination involving
continued or extended health care services, additional services for an
enrollee undergoing a course of continued treatment prescribed by a
health care provider, REQUESTS FOR TREATMENT FOR CHEMICAL DEPENDENCE OR
SUBSTANCE USE DISORDER, or home health care services following an inpa-
tient hospital admission, and shall provide notice of such determination
to the enrollee or the enrollee's designee, which may be satisfied by
notice to the enrollee's health care provider, by telephone and in writ-
ing within one business day of receipt of the necessary information
except, with respect to home health care services following an inpatient
hospital admission, OR REQUESTS FOR TREATMENT FOR CHEMICAL DEPENDENCE OR
SUBSTANCE USE DISORDER, within seventy-two hours of receipt of the
necessary information when the day subsequent to the request falls on a
weekend or holiday. Notification of continued or extended services shall
include the number of extended services approved, the new total of
approved services, the date of onset of services and the next review
date. Provided that a request for home health care services and all
necessary information is submitted to the utilization review agent prior
to discharge from an inpatient hospital admission pursuant to this
subdivision, a utilization review agent shall not deny, on the basis of
medical necessity or lack of prior authorization, coverage for home
health care services while a determination by the utilization review
agent is pending. PROVIDED THAT A REQUEST FOR TREATMENT FOR CHEMICAL
DEPENDENCE OR SUBSTANCE USE DISORDER AND ALL NECESSARY INFORMATION IS
SUBMITTED TO THE UTILIZATION REVIEW AGENT PURSUANT TO THIS SUBDIVISION,
A UTILIZATION REVIEW AGENT SHALL NOT DENY, ON THE BASIS OF MEDICAL
NECESSITY OR LACK OF PRIOR AUTHORIZATION, COVERAGE FOR CHEMICAL DEPEND-
ENCE OR SUBSTANCE USE DISORDER TREATMENT SERVICES WHILE A DETERMINATION
BY THE UTILIZATION REVIEW AGENT IS PENDING. PROVIDED THAT, UPON ADMIS-
SION TO INPATIENT AND RESIDENTIAL TREATMENT, THE UTILIZATION REVIEW
AGENT SHALL NOT DENY, ON THE BASIS OF MEDICAL NECESSITY OR LACK OF PRIOR
AUTHORIZATION, WHEN NOTICE OF ADMISSION FOR PURPOSES OF CARE COORDI-
NATION WAS PROVIDED TO THE UTILIZATION REVIEW AGENT WITHIN TWENTY-FOUR
HOURS OF AN ADMISSION; AND A REQUEST FOR TREATMENT FOR SUBSTANCE USE
S. 7882 6
DISORDER AND ALL NECESSARY INFORMATION IS SUBMITTED TO THE UTILIZATION
REVIEW AGENT PURSUANT TO THIS SUBDIVISION.
S 9. Subdivision 2 of section 4904 of the public health law, as
amended by chapter 237 of the laws of 2009, is amended to read as
follows:
2. A utilization review agent shall establish an expedited appeal
process for appeal of an adverse determination involving:
(a) continued or extended health care services, procedures or treat-
ments or additional services for an enrollee undergoing a course of
continued treatment prescribed by a health care provider home health
care services following discharge from an inpatient hospital admission
pursuant to subdivision three of section forty-nine hundred three of
this article; or
(b) an adverse determination in which the health care provider
believes an immediate appeal is warranted except any retrospective
determination. Such process shall include mechanisms which facilitate
resolution of the appeal including but not limited to the sharing of
information from the enrollee's health care provider and the utilization
review agent by telephonic means or by facsimile. The utilization review
agent shall provide reasonable access to its clinical peer reviewer
within one business day of receiving notice of the taking of an expe-
dited appeal. Expedited appeals shall be determined within two business
days of receipt of necessary information to conduct such appeal. Expe-
dited appeals which do not result in a resolution satisfactory to the
appealing party may be further appealed through the standard appeal
process, or through the external appeal process pursuant to section
forty-nine hundred fourteen of this article as applicable. PROVIDED
THAT THE INSURED OR THE INSURED'S HEALTH CARE PROVIDER NOTIFIES THE
UTILIZATION REVIEW AGENT OF ITS INTENT TO FILE AN EXTERNAL APPEAL IMME-
DIATELY UPON RECEIPT OF AN APPEAL DETERMINATION AND A REQUEST FOR AN
EXPEDITED EXTERNAL APPEAL FOR TREATMENT OF CHEMICAL DEPENDENCE OR
SUBSTANCE USE DISORDER AND ALL NECESSARY INFORMATION IS SUBMITTED WITHIN
TWENTY-FOUR HOURS OF RECEIPT OF AN APPEAL DETERMINATION, A UTILIZATION
REVIEW AGENT SHALL NOT DENY, ON THE BASIS OF MEDICAL NECESSITY OR LACK
OF PRIOR AUTHORIZATION, COVERAGE FOR SUCH TREATMENT WHILE A DETERMI-
NATION BY THE EXTERNAL REVIEW AGENT IS PENDING.
S 10. The superintendent of the department of financial services shall
select a random sampling of chemical dependence or substance use disor-
der treatment coverage determinations and provide an analysis of whether
or not such determinations are in compliance with the criteria estab-
lished in this act and report its finding to the governor, the temporary
president of the senate, and speaker of the assembly, the chairs of the
senate and assembly insurance committees, and the chairs of the senate
and assembly health committees no later than December 31, 2015.
S 11. 1. Within thirty days of the effective date of this act, the
commissioner of the office of alcoholism and substance abuse services,
superintendent of the department of financial services, and the commis-
sioner of health, shall jointly convene a workgroup to study and make
recommendations on improving access to and availability of chemical
dependence or substance use disorder treatment services in the state.
The workgroup shall be co-chaired by such commissioners and superinten-
dent, and shall also include, but not be limited to, representatives of
health care providers, insurers, additional professionals, individuals
and families who have been affected by addiction. The workgroup shall
include, but not be limited to, a review of the following:
S. 7882 7
a. Identifying barriers to obtaining necessary chemical dependence or
substance use disorder treatment services for across the state;
b. Recommendations for increasing access to and availability of chemi-
cal dependence or substance use disorder treatment services in the
state, including underserved areas of the state;
c. Identifying best clinical practices for chemical dependence or
substance use disorder treatment services;
d. A review of current insurance coverage requirements and recommenda-
tions for improving insurance coverage for chemical dependence or
substance use disorder and dependency treatment;
e. Recommendations for improving state agency communication and
collaboration relating to chemical dependence or substance use disorder
treatment services in the state;
f. Resources for affected individuals and families who are having
difficulties obtaining necessary chemical dependence or substance use
disorder treatment services; and
g. Methods for developing quality standards to measure the performance
of chemical dependence or substance use disorder treatment facilities in
the state.
2. The workgroup shall submit a report of its findings and recommenda-
tions to the governor, the temporary president of the senate, the speak-
er of the assembly, the chairs of the senate and assembly insurance
committees, and the chairs of the senate and assembly health committees
no later than December 31, 2015.
S 12. This act shall take effect January 1, 2015; provided, however,
that sections one through nine of this act shall apply to all policies
and contracts issued, delivered, renewed, modified, altered, or amended
after such date.